Can someone help explain this to me?(Another dreaded Tricare question)

kara811 · November 2011

So I just checked our mail and received a summary of EOB(explanation of benefits) and I just don't get it(I have Tricare Standard/Extra). Here's what it basically states:

Provider charged: $125

Allowed amount: $87.28

Amount not covered: $37.72

Deductible: $87.28

Amount paid to provider: $0.00

Amount provider may bill you: $87.78

So it looks like I may have to pay $87 for my recent office visit, which I am confused over. Is it because I have to meet my deductible for the entire year first before Tricare will start to actually pay for me? This is the way I understood it somehow, I've already read so many different things from the Tricare website and the handbook and still didn't see any kind of explanation.

If it helps, I know I used a network provider and the office visit was for a GYNO.

shan87 · November 2011

I dunno about the Extra part but when I was on standard I never had a deductible line. I just had to pay what was above the "allowed" amount aka amount not covered. For instance Tricare told me they cover 1 OBGYN appt a year. I went through a network provider as well, but they charged $30 more than what Tricare deemed reasonable which = amount not covered. So I paid $30 out of pocket.

Is that helpful... at all?

I dunno why you would have to pay a deductible when Standard covers them. Did you by chance already have your 1 for the year? I know it usually says THIS IS NOT A BILL. So I usually don't know what to pay until I get the actual bill.

ps .. if this is not helpful I'll DD because it's kinda giberish.

kara811 · November 2011

That's what I thought I would only have to pay, the "amount not covered" but now I am not so sure anymore. When did you change from Standard?(Extra is really just the same, except Extra is when you're using a network provider and Standard is with a non-network provider, but they're pretty much interchangeable)

Apparently they added this new deductible starting this fiscal year, so technically I believe the deductibles just started this October but I could be wrong. It's really just confusing, and if I were to be paying this much for every visit I make then I would gladly switch to Prime and make the long drive to base.

This was also my first time using Tricare, I had gone to the doctor's in June but that was paid for by my old state insurance and technically that shouldn't have been included in this fiscal year.

And don't DD Shan, it was still helpful to me, at least I know that I was understanding it correctly before about the whole amount allowed/not covered part. lol Thanks!

shayNnik · November 2011

Usually, Tricare will charge you up to the first $1000(I think it is), then they'll pay everything after that for the fiscal year(this is only for Standard).

The amount allowed is the amount that doctor is allowed to charge per the Tricare agreement. That's why not everyone will take Tricare, because they have to agree to not charge(or receive really) more than X for Y procedure/visit. So yes, you'll have to pay the amount billed to you, they are just intervening to tell the doc they aren't going to get that much. It kind of sucks in the beginning but the cap is nice because once you've paid the $1000 out of pocket for your own medical care, they'll cover the rest.

This is all dumb to me, which is why I changed DS back to Tricare Prime, and FI will be on the same thing. If you have any more questions, the 800 number for Tricare is always helpful to me, they should be able to answer all of your questions. HTH!!

shan87 · November 2011

Apt was in June. I hate deductibles in general boo TriWest for adding them.

ETA:
again why I HATE deductibles... $1000 out of pocket it huge for most families. I can't picture myself racking up that much health care costs, unless KU. Why the heck have insurance if you had to pay all of it out of pocket. (inside I know its for the what ifs.. but it still bugs me!)

Beachy730 · November 2011

Every time I get my precription filled I get one of those things in the mail, and it always says "client owes X amount." But it always also says this is not a bill, and I just ignore them. I have never been sent a bill for anything I "owe," and from my understanding I really don't have to pay it.

kara811 · November 2011

Shay: So do they follow the $1000 cap per family or the $150per individial/$300 per family deductible line? That's where it was even more confusing to me. All those 3 are listed on this EOB. If it's just the $150 I need to reach up to, I wouldn't mind staying on Standard but if I have to pay $1000 before they even start paying for me then I think that's too ridiculous. I only ever visit a doctor for the OBGYN, yearly physicals and flu shots. Like Shan said, it's like not even having an insurance at all!

Beach: Were you ever billed for actual doctor visits? I guess I'll just wait around what sort of bill the doctor will send over to me. I haven't gotten anything from the precription I filled, I paid my copay at the pharmacy for that.

Can someone help explain this to me?(Another dreaded Tricare question)

Re: Can someone help explain this to me?(Another dreaded Tricare question)

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